Authorization To Release Information Form


authorization to Release information
last name
WorK Phone
home Phone
Please sPeciFy the PurPose oF your reQuest:
Ì continuity oF care / medical treatment
(minimum document set section below) Ì emPloyment related
Ì disability(minimum document set section below)
Ì insurance
Ì continuity oF care (minimum document set section below)
Ì legal reasons
Ì changing doctor / moving From area (minimum document set section below)
Ì adoPtion Planning
Ì other (specify)____________________________
Ì research
Ì Public disclosure oF Protected health inFormation (iF yes- sKiP to section 6)
inFoRmation to Be disClosed FRom: (check as many as applicable)
Ì riverside health center
Ì riverside methodist hospital
Ì grant medical center
Ì grady memorial hospital
Ì o’bleness hospital
Ì doctors hospital
Ì mcconnell health center
Ì dublin methodist hospital Ì ohiohealth home care
Ì medcentral hospital
Ì hardin memorial hospital
Ì marion general hospital
Ì gerlach center
Ì Westerville medical campus Ì shelby hospital
Ì doctors hospital nelsonville
Ì ohiohealth Physicians group (name of practice/provider)______________________________________
Ì marion area Physicians
Ì outpatient /neighborhood care health centers (name of practice/provider) _________________________
Ì other ________________________________________________________________________________________________________________
speCiFy type oF ReCoRd ReQuested:
date oF seRViCe(s):
Ì inPatient
Ì outPatient care clinics
Ì emergency room
Ì outPatient
Ì other
Ì dates/services to be eXcluded From release ( i.e. HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency
Syndrome), PSYCHIATRIC, OR DRUG/ALCOHOL TREATMENT AND/OR ASSAULT RECORDS that may be in your medical record.
Please specify : ___________________________________________________________________________________________________________
Content to be Released
– For the record(s) selected above, specify content in area below, as either, Complete Record, minimum document set or
additional document set. each type of record may or may not contain all of the documents listed above.
minimum doCument set (check one or more of the
additional doCument set (comprised of minimum document
Ì Complete
documents, or all)
set, plus each of the following if selected):
Ì Facesheet
Ì Physician orders
Ì discharge summary
Ì Progress notes
Ì history and Physical
Ì nursing notes
Ì consults
Ì graPhics
Ì oPerative rePorts
Ì Physical theraPy/ social service notes
Ì emergency dePt. rePorts
Ì nutrition services notes
Ì Pathology
Ì consents
Ì test results (
labs, radiology, eKgs
eegs, echo)
Ì medication lists
Ì other _______________________________________
Ì assault records
anesthesia records/ other surgery documents
Ì all oF the above
Ì other/misc.
mail to organiZation/ agency
K review only (date and time) _______________
K date records Will be ready For PicK-uP _______________________
K verbal eXchange
K FaX to:
Fax #
K release to mychart
Patient identiFication label
autHoRiZation to
Release inFoRmation
1015200 (3/19/2015) Page 1 of 2


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Page of 2